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被剥夺纸质病历的医疗秘书、护士和医生对医院信息系统的使用情况及态度:病例报告

Use of and attitudes to a hospital information system by medical secretaries, nurses and physicians deprived of the paper-based medical record: a case report.

作者信息

Laerum Hallvard, Karlsen Tom H, Faxvaag Arild

机构信息

INM, Faculty of Medicine, NTNU, Trondheim, Norway.

出版信息

BMC Med Inform Decis Mak. 2004 Oct 16;4:18. doi: 10.1186/1472-6947-4-18.

Abstract

BACKGROUND

Most hospitals keep and update their paper-based medical records after introducing an electronic medical record or a hospital information system (HIS). This case report describes a HIS in a hospital where the paper-based medical records are scanned and eliminated. To evaluate the HIS comprehensively, the perspectives of medical secretaries and nurses are described as well as that of physicians.

METHODS

We have used questionnaires and interviews to assess and compare frequency of use of the HIS for essential tasks, task performance and user satisfaction among medical secretaries, nurses and physicians.

RESULTS

The medical secretaries use the HIS much more than the nurses and the physicians, and they consider that the electronic HIS greatly has simplified their work. The work of nurses and physicians has also become simplified, but they find less satisfaction with the system, particularly with the use of scanned document images.

CONCLUSIONS

Although the basis for reference is limited, the results support the assertion that replacing the paper-based medical record primarily benefits the medical secretaries, and to a lesser degree the nurses and the physicians. The varying results in the different employee groups emphasize the need for a multidisciplinary approach when evaluating a HIS.

摘要

背景

大多数医院在引入电子病历或医院信息系统(HIS)后,仍保留并更新纸质病历。本病例报告描述了一家医院的HIS,该医院对纸质病历进行扫描并予以淘汰。为全面评估该HIS,阐述了医疗秘书、护士以及医生的观点。

方法

我们使用问卷调查和访谈来评估和比较医疗秘书、护士和医生在执行基本任务时使用HIS的频率、任务执行情况以及用户满意度。

结果

医疗秘书使用HIS的频率远高于护士和医生,他们认为电子HIS极大地简化了他们的工作。护士和医生的工作也变得更加简便,但他们对该系统的满意度较低,尤其是对扫描文档图像的使用。

结论

尽管参考依据有限,但结果支持这样的观点,即取代纸质病历主要使医疗秘书受益,而护士和医生受益程度较小。不同员工群体的不同结果强调了在评估HIS时采用多学科方法的必要性。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4edb/526259/c5879dad9d50/1472-6947-4-18-1.jpg

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